By Robert Owens
Your engine company responds to a report of a motor vehicle crash (MVC). While en route, the dispatcher advises that police on the scene are reporting one person trapped inside the vehicle. Dispatch is adding a special service company (truck, squad, or heavy rescue) for extrication. You arrive and, after a scene survey and proper triage, you confirm one green (i.e., low-priority or stable) patient still inside the vehicle, which is on all four tires and has moderate damage; the doors will not open either door. Once the rest of your crew stabilizes the vehicle, you enter through the back glass and make the patient contact. You confirm your initial triage report and radio command that you have a stable patient complaining of slight neck and back pain and that extrication as well as full spinal immobilization, will be necessary.
This scenario happens in every fire department across the country on an almost daily basis. The only significant variable is how the special service company will complete the extrication. Some of you may even have already formulated a plan of action. I propose that most of the extrication plans put into action are done out of convenience for firefighters and not necessarily in the best interest of patient care. For some reason in many of the extrications I have been involved in, we seem to want to do the most complex techniques on the most critical patients, and the simplest techniques on the most stable.
This is backwards. If we are presented with a stable patient, should we not make every effort to keep the patient that way? Instead, we are often met with the old “Pull them out the window,” or “Just pop the door and get them out.” Often the indicators determining these actions are not patient care factors but based on an imaginary “clock” we are on and the desire to return to service for a more challenging or stimulating call. I have literally had firefighters tell me that it’s embarrassing for a supposed “simple” extrication to take too long, as though they were being carefully observed with a stopwatch. This conspiracy theory might make for good kitchen table talk but it has little in the way of fact.
Although time is a factor when the patient is critical, maintaining a stable patient’s status seems much more important than time. Some argue that they are trying to minimize damage to the vehicle, an excuse that holds little value since the vehicle involved in an MVC already has moderate to heavy damage with likely air bag deployment–the additional damage from proper extrication techniques will not decrease the “life” of the car, which will probably be totaled by the insurance company. Yet the “life” of the patient could be significantly decreased or altered by using the wrong extrication technique. This is very similar to a house fire in which a significant amount of damage has been done; even a “great stop” will usually end up with the house needing a complete remodeling or demolition. We don’t let the amount of damage in a house fire influence our tactics, and we should not let it influence our extrication tactics, either.
Instead of just “yanking” patients out of the car, a better option would be to make as much space as possible, minimizing moving the patient to keep his status stable. For the critical patient, creating the minimal amount of space needed to effect removal from the vehicle recognizes that time is critical for a good outcome. In such situations, an “emergency” patient move would be the prudent maneuver and smart decision. Yet, most patients are not critical. Despite this, the exact opposite of what is indicated often occurs: stable patients suffer detrimental effects because of the manipulation of the patient over obstacles, and critical patients deteriorate while we waste time performing complex extrication maneuvers.